Healthcare Provider Details

I. General information

NPI: 1659832038
Provider Name (Legal Business Name): REVA ANN BORK DPM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2019
Last Update Date: 06/26/2024
Certification Date: 06/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

397 WALLACE RD, BLDG. C STE. 411
NASHVILLE TN
37211-8028
US

IV. Provider business mailing address

397 WALLACE RD, BLDG. C STE. 411
NASHVILLE TN
37211-8028
US

V. Phone/Fax

Practice location:
  • Phone: 615-332-0330
  • Fax: 615-332-0340
Mailing address:
  • Phone: 615-332-0330
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number924
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: